7 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Liberty, TX
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1620 Magnolia St., Liberty, TX
(936) 336-8844
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
118
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-12-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
0.67
Licensed practical nurse staffing
Aide hours / resident day
2.43
Nurse aide staffing
Weekend hours
2.98
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
97.1%
2.1 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
2.7%
2.4 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.5% |
3.3%
2.8 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
18.9%
1.8 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.0% |
10.8%
6.2 pts worse
|
16.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.2% |
15.4%
0.8 pts worse
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.3% |
16.1%
0.8 pts better
|
14.9%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.5%
2.9 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
0.8%
3 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.9% |
15.0%
3.1 pts better
|
19.8%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.2%
1.3 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
89.7%
1.1 pts worse
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
12.0%
1.4 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.0% |
88.0%
18 pts worse
|
79.7%
9.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
25.9%
3.7 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Administration (6 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-18
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-06
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-08
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-07-25
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-07-25
Inspection history
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-13
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2025-06-05
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-05
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-13
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-13
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-13
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-06-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-18
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2024-05-27
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-06-25
Health
Provide training in compliance and ethics.
Corrected 2024-06-25
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-05-24
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2024-06-25
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-06-25
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-06-25
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-06-25
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-06-25
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-06-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-24
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-24
Health
Post nurse staffing information every day.
Corrected 2023-03-23
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Mortgage Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Mortgage Interest · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Individual
5% Or Greater Mortgage Interest · Individual
Corporate Officer · Individual
Nearby options
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Dayton, TX
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Baytown, TX
3-star overall rating with 2-star inspections with $12,893 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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